Client Intake Form | Glass Therapeutic Massage

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone (Day) *

Phone (Evening) *

Occupation *

Primary Physician *

Emergency Contact *

First

Last

Emergency Contact Relationship *

Emergency Contact Phone *

How did you hear about us?

Are you taking any medications? *

Are you currently pregnant? *

Do you suffer from chronic pain? *

Have you had any orthopedic injuries? *

Have you had a professional massage before? *

What type of massage are you seeking? *

What pressure do you prefer? *

Do you have any allergies or sensitivities? *

Are there any areas (feet, face, abdomen, etc) you do not want massaged? *

What are you goals for this treatment? *